Sean Whitfield - NURS 3000 - Elimination Needs (Accessibility Version)

NURS 3000 - Professional Nursing Elimination Needs Elimination Needs Harding University - Active Learning Guide, Module 9 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to...

NURS 3000 - Professional Nursing Elimination Needs Elimination Needs Harding University - Active Learning Guide, Module 9 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers; or you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Urinary Elimination: Chapter 47 1. Review and describe the physiology of urinary elimination. Kidneys: The paired kidneys are situated on either side of the spinal column, behind the peritoneal cavity. The right kidney is slightly lower than the left due to the position of the liver. They are the primary regulators of fluid and acid– base balance in the body. The functional units of the kidneys, the nephrons, filter the blood and remove metabolic wastes. In the average adult 1200 mL of blood, or about 21% of the cardiac output, passes through the kidneys every minute. Each kidney contains approximately 1 million nephrons. Ureters: Once the urine is formed in the kidneys, it moves through the collecting ducts into the calyces of the renal pelvis and from there into the ureters. In adults the ureters are from 25 to 30 cm (10 to 12 in.) long and about 1.25 cm (0.5 in.) in diameter. The upper end of each ureter is funnel shaped as it enters the kidney. The lower ends of the ureters enter the bladder at the posterior corners of the floor of the bladder (see Figure 47.1). At the junction between the ureter and the bladder, a flaplike fold of mucous membrane acts as a valve to prevent reflux (backflow) of urine up the ureters. Bladder: The urinary bladder is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion. When empty, it lies behind the symphysis pubis. In men, the bladder lies in front of the rectum and above the prostate gland (Figure 47.2); in women it lies in front of the uterus and vagina (Figure 47.3). The wall of the bladder is made up of smooth muscle layers called the detrusor muscle. The detrusor muscle allows the bladder to expand as it fills with urine, and to contract to release urine to the outside of the body during voiding. The trigone at the base of the bladder is a triangular area marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior inferior corner (see Figure 47.1). The bladder is capable of considerable distention because of rugae (folds) in the mucous membrane lining and because of the elasticity of its walls. When full, the dome of the bladder may extend above the symphysis pubis; in extreme situations, it may extend as high as the umbilicus. Normal bladder capacity is between 300 and 600 mL of urine. Urethra: The urethra extends from the bladder to the urinary meatus (opening). The male urethra is approximately 20 cm (8 in.) long and serves as a passageway for semen as well as urine (see Figure 47.2). The meatus is located at the distal end of the penis. In the adult woman, the urethra lies directly behind the symphysis pubis, anterior to the vagina, and is between 3 and 4 cm (1.5 in.) long (see Figure 47.3). The urethra serves only as a passageway for the elimination of urine. The urinary meatus is located between the labia minora, in front of the vagina and below the clitoris. NURS 3000 - Professional Nursing Elimination Needs In both men and women, the urethra has a mucous membrane lining that is continuous with the bladder and the ureters. Thus, an infection of the urethra can extend through the urinary tract to the kidneys. Women are particularly prone to urinary tract infections (UTIs) because of their short urethra and the proximity of the urinary meatus to the vagina and anus. Pelvic Floor: The vagina, urethra, and rectum pass through the pelvic floor, which consists of sheets of muscles and ligaments that provide support to the viscera of the pelvis (see Figures 47.2 and 47.3). These muscles and ligaments extend from the symphysis pubis to the coccyx forming a sling. Specific sphincter muscles contribute to the continence mechanism (see the Anatomy & Physiology Review). The internal sphincter muscle situated in the proximal urethra and the bladder neck is composed of smooth muscle under involuntary control. It provides active tension designed to close the urethral lumen. The external sphincter muscle is composed of skeletal muscle under voluntary control, allowing the individual to choose when urine is eliminated. The pelvic floor muscles (PFM) are under voluntary control and are important in controlling urination (continence). These muscles can become weakened by pregnancy and childbirth, chronic constipation, a decrease in estrogen (menopause), being overweight, aging, and lack of general fitness. 2. Describe the process of urination: Micturition, voiding, and urination all refer to the process of emptying the urinary bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors. This occurs when the adult bladder contains between 250 and 450 mL of urine. In children, a considerably smaller volume, 50 to 200 mL, stimulates these nerves. The stretch receptors transmit impulses to the spinal cord, specifically to the voiding reflex center located at the level of the second to fourth sacral vertebrae, causing the internal sphincter to relax and stimulating the urge to void. If the time and place are appropriate for urination, the conscious portion of the brain relaxes the external urethral sphincter muscle and urination takes place. If the time and place are inappropriate, the micturition reflex usually subsides until t he bladder becomes more filled and the reflex is stimulated again. Voluntary control of urination is possible only if the nerves supplying the bladder and urethra, the neural tracts of the cord and brain, and the motor area of the cerebrum are all intact. The individual must be able to sense that the bladder is full. Injury to any of these parts of the nervous system—for example, by a cerebral hemorrhage or spinal cord injury above the level of the sacral region—results in intermittent involuntary emptying of the bladder. Older adults whose cognition is impaired may not be aware of the need to urinate or able to respond to this urge by seeking toilet facilities. 3. Describe the factors affecting voiding: Numerous factors affect the volume and characteristics of the urine produced and the manner in which it is excreted. Developmental factors: Table 47.1 NURS 3000 - Professional Nursing Elimination Needs Psychosocial factors: For many individuals, a set of conditions helps stimulate the micturition reflex. These conditions include privacy, normal position, sufficient time, and, occasionally, running water. Circumstances that do not allow for the client’s accustomed conditions may produce anxiety and muscle tension. As a result, the client is unable to relax abdominal and perineal muscles and the external urethral sphincter; thus, voiding is inhibited. Clients also may voluntarily NURS 3000 - Professional Nursing Elimination Needs suppress urination because of perceived time pressures; for example, nurses often ignore the urge to void until they are able to take a break. This behavior can increase the risk of UTIs. Fluid and food intake: The healthy body maintains a balance between the amount of fluid ingested and the amount of fluid eliminated. When the amount of fluid intake increases, therefore, the output normally increases. Certain fluids, such as alcohol, increase fluid output by inhibiting the production of antidiuretic hormone. Fluids that contain caffeine (e.g., coffee, tea, and cola drinks) also increase urine production. By contrast, food and fluids high in sodium can cause fluid retention because water is retained to maintain the normal concentration of electrolytes. Medications: Many medications, particularly those affecting the autonomic nervous system, interfere with the normal urination process and may cause retention (Box 47.1). Diuretics (e.g., chlorothiazide and furosemide) increase urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into the bloodstream. Some medications may alter the color of the urine. Muscle tone: Good muscle tone is important to maintain the stretch and contractility of the detrusor muscle so the bladder can fill adequately and empty completely. Clients who require a retention catheter for a long period may have poor bladder muscle tone because continuous drainage of urine prevents the bladder from filling and emptying normally. Pelvic floor muscle tone also contributes to the ability to store and empty urine. Pathologic conditions: Some diseases and pathologies can affect the formation and excretion of urine. Diseases of the kidneys may affect the ability of the nephrons to produce urine. Abnormal amounts of protein or blood cells may be present in the urine, or the kidneys may virtually stop producing urine altogether, a condition known as renal failure. Heart and circulatory disorders such as heart failure, shock, or hypertension can affect blood flow to the kidneys, interfering with urine production. If abnormal amounts of fluid are lost through another route (e.g., vomiting or high fever), the kidneys retain water and urinary output falls. NURS 3000 - Professional Nursing Elimination Needs Processes that interfere with the flow of urine from the kidneys to the urethra affect urinary excretion. A urinary stone (calculus) may obstruct a ureter, blocking urine flow from the kidney to the bladder. Hyperplasia (enlargement) of the prostate gland, a common condition affecting older men, may obstruct the urethra, impairing urination and bladder emptying. Surgical and diagnostic procedures: Some surgical and diagnostic procedures affect the passage of urine and the urine itself. The urethra may swell following a cystoscopy, and surgical procedures on any part of the urinary tract may result in some postoperative bleeding; as a result, the urine may be red or pink tinged for a time. Spinal anesthetics can affect the passage of urine because they decrease the client’s awareness of the need to void. Surgery on structures adjacent to the urinary tract (e.g., the uterus) can also affect voiding because of swelling in the lower abdomen. 4. Describe the following terms of Altered Urine Production: Polyuria: Polyuria (or diuresis) refers to the production of abnormally large amounts of urine by the kidneys, often several liters more than the client’s usual daily output. Polyuria can follow excessive fluid intake, a condition known as polydipsia, or may be associated with diseases such as diabetes mellitus, diabetes insipidus, and chronic nephritis. Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss. Oliguria: Oliguria is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. Although oliguria may occur because of abnormal fluid losses or a lack of fluid intake, it often indicates impaired blood flow to the kidneys or impending renal failure and should be promptly reported to the primary care provider. Restoring renal blood flow and urinary output promptly can prevent renal failure and its complications. Anuria: Anuria refers to a lack of urine production. Hematuria: Proteinuria: Review Table 47.2 Average Daily Urine Output 5. Study Table 47.3 Selected Factors Associated with Altered Urinary Elimination. Familiarize yourself with the list below. Define and describe here to rehearse. Frequency: Nocturia: Nocturia is voiding 2 or more times at night. Like frequency, it is usually expressed in terms of the number of times the individual gets out of bed to void, for example, “nocturia × 4.” Urgency: Urgency is the sudden, strong desire to void. There may or may not be a great deal of urine in the bladder, but the individual feels a need to void immediately. Urgency accompanies psychologic stress and irritation of the trigone and urethra. It is also common in individuals who have poor external sphincter control and unstable bladder contractions. It is not a normal finding. Dysuria: NURS 3000 - Professional Nursing Elimination Needs Dysuria means voiding that is either painful or difficult. It can accompany a stricture (decrease in diameter) of the urethra, urinary infections, and injury to the bladder and urethra. Often clients will say they have to push to void or that burning accompanies or follows voiding. The burning may be described as severe, like a hot poker, or more subdued, like a sunburn. Often, urinary hesitancy (a delay and difficulty in initiating voiding) is associated with dysuria. Enuresis: Enuresis is involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4 or 5 years of age. Nocturnal enuresis often is irregular in occurrence and affects boys more often than girls. Diurnal (daytime) enuresis may be persistent and pathologic in origin. It affects women and girls more frequently. Urinary Incontinence: Urinary incontinence (UI), is any involuntary urine leakage. UI is a widespread problem internationally, peaking in the geriatric population (Searcy, 2017, p. 447). About 16% to 18% of postmenopausal women develop UI (Tso & Lee, 2018). UI can lead to depression, feelings of shame and embarrassment, and isolation, and can prevent individuals from traveling far from home (Kehinde, 2016; Nazarko, 2017). Kehinde (2016) reports that UI increases admission to long-term care facilities. Older adults have the highest incidence of UI, which puts them at risk for skin breakdown, recurrent UTIs, and falls related to symptoms of urgency. In spite of the high numbers of adults with UI, it is underreported and undertreated and can lead to a decreased quality of life. Many individuals do not seek help because they think nothing can be done or they think they are too old for treatment (Leaver, 2017). It is important to remember that UI is not a normal part of aging and often is treatable. Discuss the different types: The types of UI can be classified based on symptoms: stress, urgency, mixed, overflow, and transient and functional. Stress Urinary Incontinence Stress urinary incontinence (SUI), the most common type of UI, occurs because of weak pelvic floor muscles or urethral hypermobility, causing urine leakage with such activities as laughing, coughing, sneezing, or any body movement that puts pressure on the bladder. Facts that make women more likely to experience SUI include shorter urethras, the trauma to the pelvic floor associated with childbirth, and changes related to menopause. For men, SUI may result after a prostatectomy. It is important for clients to understand that SUI is not related to emotional stress but is caused by increased intra-abdominal pressure on the bladder, as well as anatomic changes to the urethra and pelvic floor muscle weakness. Urgency Urinary Incontinence Urgency urinary incontinence (UUI) is also called overactive bladder (Palmer & Willis-Gray, 2017; Tso & Lee, 2018). It is described as an urgent need to void and the inability to stop urine leakage, which can range from a few drops to soaking of undergarments. Normally the bladder contracts on urination. Individuals with an overactive bladder experience contractions while the bladder is filling, leading to an urgency to void, which can lead to UI (Nazarko, 2017). Mixed Urinary Incontinence Mixed incontinence is diagnosed when symptoms of both SUI and UUI are present. The SUI and UUI symptoms do not occur at the same time; usually the individual experiences episodes of isolated SUI and isolated UUI. It is very common among older women (Searcy, 2017). Treatment is usually based on which type of UI is the most bothersome to the client. Overflow Urinary Incontinence This is when the bladder overfills and urine leaks out due to pressure on the urinary sphincter. It occurs in men with an enlarged prostate and clients with a neurologic disorder (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury). An impaired neurologic function can interfere with the normal mechanisms of urine elimination, resulting in a NURS 3000 - Professional Nursing Elimination Needs neurogenic bladder. The client with a neurogenic bladder does not perceive bladder fullness and is therefore unable to control the urinary sphincters. Transient and Functional Urinary Incontinence Transient urinary incontinence results from factors outside of the urinary tract (e.g., medications, delirium, infection, constipation). Functional urinary incontinence (FUI) is a subcategory of transient urinary incontinence. FUI is connected with a cognitive or physical impairment, for example, unavailable toileting facilities or the inability to reach a toilet due to physical limitations. An individual with cognitive impairment may recognize the need to void but be unable to communicate the need. UTIs: A urinary tract infection (UTI) is an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra. Women are at greater risk of developing a than are men. If an infection is limited to the bladder, it can be painful and annoying. But serious health problems can result if a spreads to the kidneys. Renal Calculi: Renal calculi. In a mobile client, calcium in the urine remains dissolved because calcium and citric acid are balanced in appropriately acidic urine. With immobility and the resulting excessive amounts of calcium in the urine, this balance is no longer maintained. The urine becomes more alkaline, and the calcium salts precipitate out as crystals to form renal calculi (stones). In an immobile client in a horizontal position, the renal pelvis filled with stagnant, alkaline urine is an ideal location for calculi to form. The stones usually develop in the renal pelvis and pass through the ureters into the bladder. As the stones pass along the long, narrow ureters, they cause extreme pain and bleeding and can sometimes obstruct the urinary tract. 6. Describe the characteristics of a normal UA: Amount in 24 hrs (adult) → 1200-1500 mL Color, clarity → Straw, amber, transparent Odor → Faint aromatic Sterility → No microorganisms preset pH → 4.5 – 8 Specific gravity → 1.010 – 1.025 Glucose → Not present Ketone bodies (acetone) → Not present Blood → Not present 7. Take notes on the diagnostic tests related to urinary function: BUN: Urea, the end product of protein metabolism, is measured as blood urea nitrogen (BUN). Creatinine: Creatinine is produced in relatively constant quantities by the muscles. The creatinine clearance test uses 24-hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function. Cystoscopy: During a cystoscopy, the bladder, ureteral orifices, and urethra can be directly visualized using a cystoscope, a lighted instrument inserted through the urethra. Nurses are responsible for preparing clients before these studies and for follow-up care NURS 3000 - Professional Nursing Elimination Needs 8. Describe methods of preventing UTI: The rate of UTI is greater in women than men because of the short urethra and its proximity to the anal and vaginal areas. Most UTIs are caused by bacteria common to the intestinal environment (e.g., Escherichia coli). These gastrointestinal (GI) bacteria can colonize the perineal area and move into the urethra, especially when there is urethral trauma, irritation, or manipulation. For women who have experienced a UTI, nurses need to provide instructions about ways to prevent a recurrence. The following guidelines are useful for anyone: Drink eight 8-ounce glasses of water per day to flush bacteria out of the urinary system. Practice frequent voiding (every 2 to 4 hours) to flush bacteria out of the urethra and prevent organisms from ascending into the bladder. Void immediately after intercourse. Avoid use of harsh soaps, bubble bath, powder, or sprays in the perineal area. These substances can be irritating to the urethra and encourage inflammation and bacterial infection. Avoid tight-fitting pants or other clothing that creates irritation to the urethra and prevents ventilation of the perineal area. Wear cotton rather than nylon underclothes. Accumulation of perineal moisture facilitates bacterial growth. Cotton enhances ventilation of the perineal area. Girls and women should always wipe the perineal area from front to back following urination or defecation in order to prevent introduction of GI bacteria into the urethra. If recurrent urinary infections are a problem, take showers rather than baths. Bacteria present in bath water can readily enter the urethra. 9. Managing Urinary Incontinence: It is important to remember that UI is not a normal part of aging and often is treatable. The preliminary assessment and identification of the symptoms of UI are truly within the scope of nursing practice. All clients should be asked about their voiding patterns. Older adults who are incontinent while in their home or who manage to contain or conceal their incontinence from others do not consider themselves incontinent. Therefore, if asked if they are incontinent, they may deny it. However, asking if they lose urine when they cough, sneeze, or laugh or if they need to use some type of incontinence product may provide more accurate information. Independent nursing interventions for clients with UI include (a) a behavior-oriented continence training program that may consist of bladder retraining, habit training, and pelvic floor muscle exercises; (b) meticulous skin care; and (c) for males, application of an external drainage device (condom-type catheter device). 10. Bladder Retraining: Bladder retraining promotes complete bladder contraction and emptying and requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to void. The goals are to gradually lengthen the intervals between urination to correct the client’s frequent urination, to stabilize the bladder, and to diminish urgency. This form of training may be used for clients who have bladder instability and urge incontinence. Delayed voiding provides larger voided volumes and longer intervals between voiding. Initially, voiding may be encouraged every 2 to 3 hours except during sleep and then every 4 to 6 hours. A vital component of bladder training is inhibiting the urge-to-void sensation. To do this, the nurse instructs the client to practice deep, slow breathing until the urge diminishes or disappears. This is performed every time the client has a premature urge to void. Guidelines for bladder retraining are in the Practice Guidelines. NURS 3000 - Professional Nursing Elimination Needs 11. Pelvic Floor Muscle Exercises: Pelvic floor muscle (PFM), or Kegel, exercises help to strengthen pelvic floor muscles (see Figures 47.2 and 47.3) and can reduce or eliminate episodes of incontinence. The client can identify the perineal muscles by tightening the anal sphincter as if to control the passing of gas, around the vagina and the urethra as if trying to stop urine mid flow. When the exercise is properly performed, contraction of the muscles of the buttocks and thighs is avoided. PFM exercises can be performed anytime, anywhere, sitting or standing. Specific client instructions are summarized in Client Teaching. 12. External Urinary Devices: To prevent the complications and inconveniences associated with incontinence in males, an external urinary device, also referred to as a penile sheath or condom catheter, attached to a urinary drainage system may be used. External urinary devices may be more comfortable than an indwelling catheter and cause fewer UTIs. Latex or silicone devices are available. The silicone penile sheath has two advantages in that it allows the client or his caregivers to assess the skin without removing the sheath and it has oxygen and water vapor transmission properties, allowing the skin to breathe (Nazarko, 2018, p. 112). Urinary Catheterization: Urinary catheterization is the introduction of a catheter through the urethra into the urinary bladder. This is usually performed only when absolutely necessary, because the danger exists of introducing microorganisms into the bladder. Box 47.3 Preventing or Reducing the Risk of CAUTI NURS 3000 - Professional Nursing Elimination Needs NURS 3000 - Professional Nursing Elimination Needs Urinary Diversions: Urinary Diversions A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Clients with bladder cancer often need a urinary diversion when the bladder must be removed or bypassed. There are two categories of diversions: incontinent and continent. Incontinent With incontinent diversions clients have no control over the passage of urine and require the use of an external ostomy appliance to contain the urine. Urinary diversions may or may not involve the removal of the bladder (cystectomy). Examples of incontinent diversions include ureterostomy, nephrostomy, vesicostomy, and ileal conduits. A ureterostomy is when one or both of the ureters may be brought directly to the side of the abdomen to form small stomas. This procedure, however, has some disadvantages in that the stomas provide direct access for microorganisms from the skin to the kidneys, the small stomas are difficult to fit with an appliance to collect the urine, and they may narrow, impairing urine drainage. A nephrostomy diverts urine from the kidney via a catheter inserted into the renal pelvis to a nephrostomy tube and bag (Figure 47.12). Continent Continent urinary diversion involves creation of a mechanism that allows the client to control the passage of urine, either by intermittent catheterization of the internal reservoir (e.g., Kock pouch) or by creating a neobladder or internal pouch. The Kock (pronounced “coke”) pouch, or continent ileal bladder conduit, also uses a portion of the ileum to form a reservoir for urine (Figure 47.14). In this procedure, nipple valves are formed by doubling the tissue backward into the reservoir where the pouch connects to the skin and the ureters connect to the pouch. These valves close as the pouch fills with urine, preventing leakage and reflux of urine back toward the kidneys. The client empties the pouch by inserting a clean catheter approximately every 2 to 3 hours at first and increases to every 5 to 6 hours as the pouch expands. Between catheterizations, a small dressing is worn to protect the stoma and clothing. II. Fecal Elimination: Chapter 48 1. Physiology of Defecation: Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). Defecation is the expulsion of feces from the anus and rectum. It is also called a bowel movement. The frequency of defecation is highly individual, varying from several times per day to two or three times per week. The amount defecated also varies among individuals. When peristaltic waves move the feces into the sigmoid colon and the rectum, the sensory nerves in the rectum are stimulated and the individual becomes aware of the need to defecate. When the internal anal sphincter relaxes, feces move into the anal canal. After the individual is seated on a toilet or bedpan, the external anal sphincter is relaxed voluntarily. Expulsion of the feces is assisted by contraction of the abdominal muscles and the diaphragm, which increases abdominal pressure, and by contraction of the muscles of the pelvic floor, which moves the feces through the anal canal. Normal defecation is facilitated by (a) thigh flexion, which increases the pressure within the abdomen, and (b) a sitting position, which increases the downward pressure on the rectum. NURS 3000 - Professional Nursing Elimination Needs If the defecation reflex is ignored, or if defecation is consciously inhibited by contracting the external sphincter muscle, the urge to defecate normally disappears for a few hours before occurring again. Repeated inhibition of the urge to defecate can result in expansion of the rectum to accommodate accumulated feces and eventual loss of sensitivity to the need to defecate. Constipation can be the ultimate result. 2. Table 48.1 Characteristics of Normal and Abnormal Feces: 3. Factors that Affect Defecation: Diet: Sufficient bulk (cellulose, fiber) in the diet is necessary to provide fecal volume. Inadequate intake of dietary fiber contributes to the risk of developing obesity, type 2 diabetes, coronary artery disease, and colon cancer. Fiber is classified into two categories: insoluble fiber and soluble fiber. Insoluble fiber promotes the movement of material through the digestive system and increases stool bulk. Sources of insoluble fiber include whole-wheat flour, wheat bran, nuts, and many vegetables. Soluble fiber dissolves in water to form a gel-like material. It can help lower blood cholesterol and glucose levels (Mayo Clinic, 2018). Sources of soluble fiber include oats, peas, beans, apples, citrus fruits, carrots, barley, and psyllium. The Mayo Clinic recommends the following daily amount of fiber: Men ages 50 and younger: 38 grams Men ages 51 and older: 30 grams Women ages 50 and younger: 25 grams Women ages 51 and older: 21 grams. It is important to drink plenty of water because fiber works best when it absorbs water. Fluid Intake: NURS 3000 - Professional Nursing Elimination Needs Fluid Intake and Output Even when fluid intake is inadequate or output (e.g., urine or vomitus) is excessive for some reason, the body continues to reabsorb fluid from the chyme as it passes along the colon. The chyme becomes drier than normal, resulting in hard feces. In addition, reduced fluid intake slows the chyme’s passage along the intestines, further increasing the reabsorption of fluid from the chyme. Healthy fecal elimination usually requires a daily fluid intake of 2000 to 3000 mL. If chyme moves abnormally quickly through the large intestine, however, there is less time for fluid to be absorbed into the blood; as a result, the feces are soft or even watery. Activity: Activity stimulates peristalsis, thus facilitating the movement of chyme along the colon. Weak abdominal and pelvic muscles are often ineffective in increasing the intra-abdominal pressure during defecation or in controlling defecation. Weak muscles can result from lack of exercise, immobility, or impaired neurologic functioning. Clients confined to bed are often constipated. Psychologic Factors: Some individuals who are anxious or angry experience increased peristaltic activity and subsequent nausea or diarrhea. In contrast, individuals who are depressed may experience slowed intestinal motility, resulting in constipation. How someone responds to these emotional states is the result of individual differences in the response of the enteric nervous system to vagal stimulation from the brain. Defecation Habits: Early bowel training may establish the habit of defecating at a regular time. Many individuals defecate after breakfast due to the gastrocolic reflex (increased peristalsis of the colon after food has entered the stomach). If an individual ignores this urge to defecate, water continues to be reabsorbed, making the feces hard and difficult to expel. When the normal defecation reflexes are inhibited or ignored, these conditioned reflexes tend to be progressively weakened. When habitually ignored, the urge to defecate is ultimately lost. Adults may ignore these reflexes because of the pressures of time or work. Hospitalized clients may suppress the urge because of embarrassment about using a bedpan, because of lack of privacy, or because defecation is too uncomfortable. Medications: Some drugs have side effects that can interfere with normal elimination. Some cause diarrhea; others, such as large doses of certain tranquilizers and repeated administration of opioids, cause constipation because they decrease gastrointestinal activity through their action on the central nervous system. Iron supplements act more locally on the bowel mucosa and can cause constipation or diarrhea. Some medications directly affect elimination. Laxatives are medications that stimulate bowel activity and so assist fecal elimination. Other medications soften stool, facilitating defecation. Certain medications suppress peristaltic activity and may be used to treat diarrhea. Medications can also affect the appearance of the feces. Any drug that causes gastrointestinal bleeding (e.g., aspirin products) can cause the stool to be red or black. Iron salts lead to black stool because of the oxidation of the iron; antibiotics may cause a gray-green discoloration; and antacids can cause a whitish discoloration or white specks in the stool. Pepto-Bismol, a common OTC drug, causes stools to be black. Diagnostic Procedures: Before certain diagnostic procedures, such as visualization of the colon (colonoscopy or sigmoidoscopy), the client is restricted from ingesting food or fluid. The client may also be given a cleansing enema prior to the examination. In these instances normal defecation usually will not occur until eating resumes. NURS 3000 - Professional Nursing Elimination Needs Anesthesia and Surgery: General anesthetics cause the normal colonic movements to cease or slow by blocking parasympathetic stimulation to the muscles of the colon. Clients who have regional or spinal anesthesia are less likely to experience this problem. Surgery that involves direct handling of the intestines can cause temporary stoppage of intestinal movement. This condition, called ileus, usually lasts 24 to 48 hours. Listening for bowel sounds that reflect intestinal motility is an important nursing assessment following surgery. Pathologic Conditions: Spinal cord injuries and head injuries can decrease the sensory stimulation for defecation. Impaired mobility may limit the client’s ability to respond to the urge to defecate and the client may experience constipation. Or, a client may experience fecal incontinence because of poorly functioning anal sphincters. Pain: Clients who experience discomfort when defecating (e.g., following hemorrhoid surgery) often suppress the urge to defecate to avoid the pain. Such clients can experience constipation as a result. Clients taking opioid analgesics for pain may also experience constipation as a side effect of the medication. 4. Common Fecal Elimination Problems: Constipation: Signs, Symptoms, Causes, and Interventions: Constipation may be defined as fewer than three bowel movements per week. This infers the passage of dry, hard stool or the passage of no stool. It occurs when the movement of feces through the large intestine is slow, thus allowing time for additional reabsorption of fluid from the large intestine. Associated with constipation are difficult evacuation of stool and increased effort or straining of the voluntary muscles of defecation. The individual may also have a feeling of incomplete stool evacuation after defecation. However, it is important to define constipation in relation to the individual’s regular elimination pattern. Some individuals normally defecate only a few times a week; others defecate more than once a day. Careful assessment of the client’s habits is necessary before a diagnosis of constipation is made. Box 48.1 lists the common characteristics of constipation. Box 48.1 Common Characteristics of Constipation Decreased frequency of defecation Hard, formed stools Straining at stool; painful defecation Reports of rectal fullness or pressure or incomplete bowel evacuation Abdominal pain, cramps, or distention Anorexia, nausea Headache Many causes and factors contribute to constipation. Among them are the following: Insufficient fiber intake Insufficient fluid intake Insufficient activity or immobility Irregular defecation habits Change in daily routine Lack of privacy Chronic use of laxatives or enemas Irritable bowel syndrome (IBS) Pelvic floor dysfunction or muscle damage Poor motility or slow transit NURS 3000 - Professional Nursing Elimination Needs Neurologic conditions (e.g., Parkinson’s disease), stroke, or paralysis Emotional disturbances such as depression or mental confusion Medications such as opioids, iron supplements, antihistamines, antacids, and antidepressants Habitual denial and ignoring the urge to defecate. Fecal Impaction: Signs, Symptoms, Causes, and Interventions: Fecal impaction is a mass or collection of hardened feces in the folds of the rectum. Impaction results from prolonged retention and accumulation of fecal material. In severe impactions the feces accumulate and extend well up into the sigmoid colon and beyond. A client who has a fecal impaction will experience the passage of liquid fecal seepage (diarrhea) and no normal stool. The liquid portion of the feces seeps out around the impacted mass. Impaction can also be assessed by digital examination of the rectum, during which the hardened mass can often be palpated. Along with fecal seepage and constipation, symptoms include frequent but nonproductive desire to defecate and rectal pain. A generalized feeling of illness results; the client becomes anorexic, the abdomen becomes distended, and nausea and vomiting may occur. The causes of fecal impaction are usually poor defecation habits and constipation. Also, the administration of medications such as anticholinergics and antihistamines will increase the client’s risk in the development of a fecal impaction. The barium used in radiologic examinations of the upper and lower gastrointestinal tracts can also be a causative factor. Therefore, after these examinations, laxatives or enemas are usually given to ensure removal of the barium. Digital examination of the impaction through the rectum should be done gently and carefully. Although digital rectal examination is within the scope of nursing practice, some agency policies require a primary care provider’s order for digital manipulation and removal of a fecal impaction. Although fecal impaction can generally be prevented, treatment of impacted feces is sometimes necessary. When fecal impaction is suspected, the client is often given an oil retention enema, a cleansing enema 2 to 4 hours later, and daily additional cleansing enemas, suppositories, or stool softeners. If these measures fail, manual removal is often necessary. Diarrhea: Signs, Symptoms, Causes, and Interventions: Diarrhea refers to the passage of liquid feces and an increased frequency of defecation. It is the opposite of constipation and results from rapid movement of fecal contents through the large intestine. Rapid passage of chyme reduces the time available for the large intestine to reabsorb water and electrolytes. Some individuals pass stool with increased frequency, but diarrhea is not present unless the stool is relatively unformed and excessively liquid. The individual with diarrhea finds it difficult or impossible to control the urge to defecate. Diarrhea and the threat of incontinence are sources of concern and embarrassment. Often, spasmodic cramps are associated with diarrhea. Bowel sounds are increased. With persistent diarrhea, irritation of the anal region extending to the perineum and buttocks generally results. Fatigue, weakness, malaise, and emaciation are the results of prolonged diarrhea. When the cause of diarrhea is irritants in the intestinal tract, diarrhea is thought to be a protective flushing mechanism. It can create serious fluid and electrolyte losses in the body, however, that can develop within frighteningly short periods of time, particularly in infants, small children, and older adults. The prevalence of Clostridium difficile infection (CDI), which produces mucoid and foul-smelling diarrhea, has been increasing in recent years. Clients at the highest risk for the development of CDI include immunosuppressed individuals, clients of advanced age, and those who have recently used antimicrobial agents, usually fluoroquinolones (Sams & Kennedy-Malone, 2017). Older adults are at the greatest risk due to underlying disease(s) and greater exposure in hospitals and extended care facilities. Infection control against CDI includes hand hygiene, contact precautions, and cleaning of surfaces with a bleach solution. All individuals involved in the care of the client need to be reminded to wash their hands with soap and water because alcohol-based hand gels are not effective against C. difficile. Also, wearing gloves when coming into contact with soiled linens is needed to prevent the spread of the bacteria and spores that exist with C. difficile (Smith & Taylor, 2016). Table 48.3 lists some of the major causes of diarrhea and the physiologic responses of the body. NURS 3000 - Professional Nursing Elimination Needs The irritating effects of diarrhea stool increase the risk for skin breakdown. Therefore, the area around the anal region should be kept clean and dry and be protected with zinc oxide or other ointment. In addition, a fecal collector can be used (see page 1263). Bowel Incontinence: Signs, Symptoms, Causes, and Interventions: Bowel incontinence, also called fecal incontinence, refers to the loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter. The incontinence may occur at specific times, such as after meals, or it may occur irregularly. Fecal incontinence is generally associated with impaired functioning of the anal sphincter or its nerve supply, such as in some neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle. The prevalence of bowel incontinence increases with age. Bowel incontinence is an emotionally distressing problem that can ultimately lead to social isolation. Afflicted individuals withdraw into their homes or, if in the hospital, the confines of their room, to minimize the embarrassment associated with soiling. Treatment depends on the cause of the fecal incontinence. Many help manage their situation by modifying their diet (e.g., decreasing alcohol, caffeine, greasy or spicy food, gasproducing vegetables). Weight loss improves continence by removing weight on the pelvic muscles. Pelvic muscle function is also enhanced by exercises. A regular defecation schedule can also help (Gump & Schmelzer, 2016). Several surgical procedures are used for the treatment of fecal incontinence. These include repair of the sphincter and bowel diversion or colostomy. Flatulence: Signs, Symptoms, Causes, and Interventions: The three primary sources of flatus are (1) action of bacteria on the chyme in the large intestine, (2) swallowed air, and (3) gas that diffuses between the bloodstream and the intestine. Most gases that are swallowed are expelled through the mouth by eructation (belching). However, large amounts of gas can accumulate in the stomach, resulting in gastric distention. The gases formed in the large intestine are chiefly absorbed through the intestinal capillaries into the circulation. Flatulence is the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines (intestinal distention). Flatulence can occur in the colon from a variety of causes, such as foods (e.g., cabbage, onions), abdominal surgery, or opioids. If the gas is propelled by increased colon activity before it can be absorbed, it may be expelled through the anus. If excessive gas cannot be expelled through the anus, it may be necessary to insert a rectal tube to remove it. Hemorrhoids: Signs, Symptoms, Causes, and Interventions: Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool. When the veins become distended, as can occur with repeated pressure, a condition known as hemorrhoids occurs (Figure 48.2). NURS 3000 - Professional Nursing Elimination Needs Signs: Bright red blood in your stool, on toilet paper, or in your toilet bowl. Pain and irritation around your anus. Swelling or a hard lump around your anus. Itching. Symptoms: Bright red blood in your stool, on toilet paper, or in your toilet bowl Pain and irritation around your anus Swelling or a hard lump around your anus Itching Causes: Often strain during bowel movements Are pregnant Have a family history of hemorrhoids Are older Have long-term or chronic constipation or diarrhea Interventions: Apply a hemorrhoid cream or suppository containing hydrocortisone that you can buy without a prescription. You also can use pads containing witch hazel or a numbing medicine. Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water for 10 to 15 minutes two or three times a day. Educate patients on dietary and lifestyle modifications to prevent constipation and strain during bowel movements. Provide information on over-the-counter topical treatments for symptom relief. Offer guidance on sitz baths for soothing relief. Encourage increased fiber intake and hydration to soften stools. 5. Nursing Interventions to Promote Healthy Bowel Elimination. pp. 1255-1256 Promoting Regular Defecation The nurse can help clients achieve regular defecation by attending to (a) the provision of privacy, (b) timing, (c) nutrition and fluids, (d) exercise, and (e) positioning. See Client Teaching for healthy habits related to bowel elimination. Privacy Privacy during defecation is extremely important to many clients. The nurse should therefore provide as much privacy as possible for such clients but may need to stay with those who are too weak to be left alone. Some clients also prefer to wipe, wash, and dry themselves after defecating. A nurse may need to provide water, washcloth, and towel or wipes for this purpose. Timing A client should be encouraged to defecate when the urge is recognized. To establish regular bowel elimination, the client and nurse can discuss when peristalsis normally occurs and provide time for defecation. Many clients have wellestablished routines. Other activities, such as bathing and ambulating, should not interfere with the defecation time. Nutrition and Fluids NURS 3000 - Professional Nursing Elimination Needs The diet a client needs for regular normal elimination varies, depending on the kind of feces the client currently has, the frequency of defecation, and the types of foods that the client finds assist with normal defecation. Client Teaching Healthy Defecation Establish a regular exercise regimen. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. Maintain fluid intake of 2000 to 3000 mL/day. Do not ignore the urge to defecate. Allow time to defecate, preferably at the same time each day. Avoid OTC medications to treat constipation and diarrhea. For Constipation Increase daily fluid intake, and instruct the client to drink hot liquids, warm water with a squirt of fresh lemon, and fruit juices, especially prune juice. Include fiber in the diet, that is, foods such as raw fruit, bran products, and wholegrain cereals and bread. For Diarrhea Encourage oral intake of fluids and bland food. Eating small amounts can be helpful because small amounts are more easily absorbed. Excessively hot or cold fluids should be avoided because they stimulate peristalsis. In addition, highly spiced foods and high-fiber foods can aggravate diarrhea. See Client Teaching for details about managing diarrhea. For Flatulence Limit carbonated beverages, the use of drinking straws, and chewing gum—all of which increase the ingestion of air. Gas-forming foods, such as cabbage, beans, onions, and cauliflower, should also be avoided. Exercise Regular exercise helps clients develop a regular defecation pattern. A client with weak abdominal and pelvic muscles (which delay normal defecation) may be able to strengthen them with the following isometric exercises: In a supine position, the client tightens the abdominal muscles as though pulling them inward, holding them for about 10 seconds and then relaxing them. This should be repeated 5 to 10 times, four times a day, depending on the client’s health. Again in a supine position, the client can contract the thigh muscles and hold them contracted for about 10 seconds, repeating the exercise 5 to 10 times, four times a day. This helps the client confined to bed gain strength in the thigh muscles, thereby making it easier to use a bedpan. Positioning Although the squatting position best facilitates defecation, on a toilet seat the best position for most individuals seems to be leaning forward. 6. Bowel Diversions: Why is the location of the ostomy important? The location of the ostomy influences the character and management of the fecal drainage. The farther along the bowel, the more formed the stool (because the large bowel reabsorbs water from the fecal mass) and the more control over the frequency of stomal discharge can be established. For example: What type of stool is expected from an ostomy in these different locations? Ileostomy: NURS 3000 - Professional Nursing Elimination Needs An ileostomy produces liquid fecal drainage. Drainage is constant and cannot be regulated. Ileostomy drainage contains some digestive enzymes, which are damaging to the skin. For this reason, ileostomy clients must wear an appliance continuously and take special precautions to prevent skin breakdown. Compared to colostomies, however, odor is minimal because fewer bacteria are present. Ascending Colostomy: An ascending colostomy is similar to an ileostomy in that the drainage is liquid and cannot be regulated, and digestive enzymes are present. Odor, however, is a problem requiring control. Transverse Colostomy: A transverse colostomy produces a malodorous, mushy drainage because some of the liquid has been reabsorbed. There is usually no control. Descending Colostomy: A descending colostomy produces increasingly solid fecal drainage. Stools from a sigmoidostomy are of normal or formed consistency, and the frequency of discharge can be regulated. Clients with a sigmoidostomy may not have to wear an appliance at all times, and odors can usually be controlled. 7. Management of an Ostomy: Describe holistic nursing care for a client with an ostomy. Stoma and Skin Care Care of the stoma and skin is important for all clients who have ostomies. The fecal material (effluent) from a colostomy or ileostomy is irritating to the peristomal skin, with the resulting moisture-associated skin damage being the most common cause of peristomal skin problems. This is particularly true of stool from an ileostomy, which contains digestive enzymes. In addition to pain and discomfort, the peristomal skin damage can cause difficulty in obtaining an adequate seal from the appliance, which causes the client embarrassment and stress from the leakage. It is important to assess the peristomal skin for irritation each time the appliance is changed. Any irritation or skin breakdown needs to be treated immediately. The skin is kept clean by washing off any excretion with water and drying thoroughly. If soap is used, it should not contain cream or lotion that may leave a residue, which can interfere with the skin barrier adhesive (Hollister, 2017). Qsen Patient-Centered Care Ostomy Care When providing nursing care for the client with an ostomy, the nurse should consider the following: Provide the client with the names and phone numbers of a WOCN, supply vendor, and other resource people to contact when needed. Provide pertinent internet resources for information and support. Inform the client of signs to report to a healthcare provider (e.g., peristomal redness, skin breakdown, and changes in stomal color). Provide client and family education regarding care of the ostomy and appliance when traveling. Educate the client and family regarding infection control precautions, including proper disposal of used pouches since these cannot be flushed down a toilet. Younger clients may have special concerns about odor and appearance. Provide information about community support groups. A visit from someone who has had an ostomy under similar circumstances may be helpful. Urinary Retention: NURS 3000 - Professional Nursing Elimination Needs When emptying of the bladder is impaired, urine accumulates and the bladder becomes overdistended, a condition known as urinary retention. Overdistention of the bladder causes poor contractility of the detrusor muscle, further impairing urination. Common causes of urinary retention include benign prostatic hyperplasia (BPH), surgery, and some medications (see Box 47.1). Acute urinary retention is the most common complication postoperatively (Hoke & Bradway, 2016). Clients with urinary retention may experience overflow incontinence, eliminating 25 to 50 mL of urine at frequent intervals. The bladder is firm and distended on palpation and may be displaced to one side of the midline. Nursing Management Assessing A complete assessment of a client’s urinary function includes the following: Nursing history Physical assessment of the genitourinary system, hydration status, and examination of the urine Relating the data obtained to the results of any diagnostic tests and procedures. Nursing History The nurse determines the client’s normal voiding pattern and frequency, appearance of the urine and any recent changes, any past or current problems with urination, the presence of an ostomy, and factors influencing the elimination pattern. Examples of interview questions to elicit this information are shown in the Assessment Interview. The number of questions asked depends on the individual and the responses to the first three categories. Physical Assessment Complete physical assessment of the urinary tract usually includes percussion of the kidneys to detect areas of tenderness. Palpation and percussion of the bladder are also performed. If the client’s history or current problems indicate a need for it, the urethral meatus of both male and female clients is inspected for swelling, discharge, and inflammation. Assessment Interview Urinary Elimination Voiding Pattern How many times do you urinate during a 24-hour period? Has this pattern changed recently? Do you need to get out of bed to void at night? How often? Description of Urine and any Changes How would you describe your urine in terms of color, clarity (clear, transparent, or cloudy), and odor (faint or strong)? Urinary Elimination Problems What problems have you had or do you now have with passing your urine? Passage of small amounts of urine? Voiding at more frequent intervals? Trouble getting to the bathroom in time, or feeling an urgent need to void? Painful voiding? Difficulty starting urine stream? Frequent dribbling of urine or feeling of bladder fullness associated with voiding small amounts of urine? Reduced force of stream? Accidental leakage of urine? If so, when does this occur (e.g., when coughing, laughing, or sneezing; at night; during the day)? Past urinary tract illness such as infection of the kidney, bladder, or urethra? History of renal, ureteral, or bladder surgery? Factors Influencing Urinary Elimination Medications. What medications are you taking? Do you know if any of your medications increase urinary output or cause retention of urine? Note specific medication and dosage. NURS 3000 - Professional Nursing Elimination Needs Fluid intake. How much and what kind of fluid do you drink each day (e.g., six glasses of water, two cups of coffee, three cola drinks with or without caffeine)? Environmental factors. Do you have any problems with toileting (mobility, removing clothing, toilet seat too low, facility without grab bar)? Stress. Are you experiencing any major stress? If so, what are the stressors? Do you think these affect your urinary pattern? Disease. Have you had or do you have any illnesses that may affect urinary function, such as hypertension, heart disease, neurologic disease, cancer, prostatic enlargement, or diabetes? Diagnostic procedures and surgery. Have you recently had a cystoscopy or anesthetic?